ORIGINAL ARTICLE

Management of severe cleft maxillary deficiency with distraction

osteogenesis: Procedure and results

Alvaro A. Figueroa, DDS, MS,a and John W. Polley, MDb

Chicago, Ill.

Distraction osteogenesis has become an important technique to treat craniofacial skeletal dysplasia. In this
study, the technique of maxillary distraction with a rigid external distraction device is presented.
Cephalometric results in the first 14 consecutive patients are analyzed. The study sample consisted of 14
patients with various cleft types and maxillary hypoplasia treated with the rigid external distraction
technique. Analysis of the predistraction and postdistraction cephalometric radiographs revealed significant
skeletal maxillary advancement. All patients had correction of the maxillary hypoplasia with positive skeletal
convexity and dental overjet after maxillary distraction. The morbidity for the procedure was minimal.
Surgical and orthodontic procedures are thoroughly described. (Am J Orthod Dentofacial Orthop
1999;115:1-12)

D istraction osteogenesis is rapidly becom-
ing an alternative technique to treat craniofacial dys-
plasias. It was initially used successfully to treat unilat-
eral or bilateral mandibular dysplasias.1 The applica-
tion to other regions of the craniofacial skeleton are
currently being explored, and animal and clinical trials
have been conducted.2-8 The purpose of this report is to
present our technique for maxillary distraction osteo-
genesis in cleft patients with severe maxillary deficien-
cy, with the use of a rigid external distraction (RED)
device (Fig 1), to describe the orthodontic appliance
required to deliver the traction force through the denti-
tion to the maxillary bone, and to present the clinical
and cephalometric results in our initial series of 14 con-
secutive patients.
MATERIAL AND METHODS
Patient Selection and Evaluation
Patients were selected based on cause and severity of
the maxillary hypoplasia. Presurgical records were
obtained including a comprehensive speech evaluation
by the speech and language pathologist. The cephalo-
metric radiographs are obtained at the completion of dis-
traction and at yearly intervals to monitor outcome.
Time was spent with the patient and the patient’s family,
explaining in detail the distraction process with pho-
From the Craniofacial Center and Department of Orthodontics,
University of Illinois at Chicago.
aAssociate Professor, Department of Orthodontics.
bDirector, Craniofacial Center; Associate Professor, Department of Surgery.
Reprint requests to: Alvaro A. Figueroa, DDS, MS, Craniofacial Center, Uni-
versity of Illinois at Chicago, 811 S. Paulina St., Rm. 161 COD M/C 588,
Chicago, IL 60612; E-mail, Afig@uic.edu
Copyright © 1999 by the American Association of Orthodontists.
0889-5406/99/$8.00 + 0 8/1/91527
tographs and video imaging, as well as discussion with
other patients and their families who have undergone
the procedure. The patient and parents were thoroughly
familiarized with the mechanics of the distraction appa-
ratus and distraction protocol before the procedure.
Intraoral Splint
In order to apply traction to the maxilla through the
dentition, a rigid intraoral splint needs to be fabricated.
Orthodontic bands with 0.050 inch headgear tubes are
fitted either on the second primary molars (children
under 6 years) or first permanent molars and an algi-
nate or compound impression is taken of the maxillary
arch. The impression is poured with dental stone. The
splint is made on the working model, with 0.045 or
0.050 stainless steel rigid orthodontic wire. If the
patient does not have orthodontic brackets, the labial
and palatal wires are bent in close contact with most of
the maxillary teeth. If the patient has orthodontic
brackets, the labial wire has to be bent outward and
gingivally to clear the existing appliances. If needed, a
transpalatal bar can be added to increase rigidity. Con-
necting wires between the labial and palatal arches
through the embrasures between the lateral and canine
teeth bilaterally or in any other area where the wire can
be passed without interfering with the occlusion may
also be incorporated (Fig 2).
The basic design of the splint has been successful-
ly used in patients undergoing protractive face mask
therapy. The rigid splint is then tried in the patient,
assuring adequate fit, and two markings are done on
the labial wire just medial to both commissures. The
splint is removed from the patient’s mouth and two
straight pieces of 0.050 or 0.060 inch rigid stainless
1
2 Figueroa and Polley
Fig 1. A, Disassembled RED device with activating and
assembling screwdrivers. B, Patient undergoing RED.
Note anterior adjustable outrigger system connected
with surgical wires to the hooks from the intraoral appli-
ance. C, Close-up view of the distraction screws linked
to the intraoral splint through the external traction hooks
with surgical wires.
steel orthodontic wire are soldered perpendicular to the
labial wire. These vertical wires have a short end towards
the vestibule that eventually will be used as intraoral
hooks. The long end of the vertical wire is marked while
the device is in the mouth to bend the external traction
hooks (Fig 2). The wire is bent under, over and anterior
to the lip. The ends of the wire are bent in a circle to
American Journal of Orthodontics and Dentofacial Orthopedics
January 1999
eliminate sharp ends and to have a rigid eyelet from
where to apply the traction. This traction eyelet is posi-
tioned at the level of the floor of the nose or at any other
desired level to control rotational movements of the
maxilla (Fig 2). The purpose of this external hook is to
avoid any irritation to the lip while applying traction and
also to control the direction of the traction forces, rela-
tive to the approximate center of resistance of the max-
illa.9,10 The completed splint is cemented in the clinical
setting and at the time of surgery, circumdental wires are
passed through most of the maxillary teeth to increase
rigidity and stability (Fig 3).
In certain instances, it becomes necessary to do an
intraoral splint to an abnormal arch form, knowing that
after distraction, the patient will undergo further ortho-
dontic treatment or surgical orthodontic expansion of
the arch. If it is determined that the arch will be expand-
ed surgically at the time of the required osteotomy for
distraction, the cast has to be cut, aligned, and the splint
made to the newly desired maxillary arch form.
It is preferable to do arch expansion procedures
before or after maxillary distraction to avoid moving
the maxillary bone simultaneously in several directions
where vector control can become more difficult. If the
clinician desires to expand simultaneously with anteri-
or distraction, an expansion screw can be incorporated
into the splint, which has to be split into two segments,
but the rigidity of the device may be compromised.
The intraoral splint can also be made with a com-
mercially available orthodontic headgear facebow with
a long external outer bow and an inner bow without
loops. The inner bow is bent to the desired arch form,
and the loose ends are passed through the headgear
tubes for future soldering. The outer bow is bent down-
ward and anteriorly, in order to clear the upper lip. The
advantage of using a face bow is that the wires for the
traction hooks (outer bow) are strong and rigid and the
traction hooks are already soldered (Fig 4). It is diffi-
cult to use the face bow in maxillary arches with poor
arch form or in young children because it is difficult to
adapt the inner bow to the teeth, making circumdental
wiring difficult.
In younger patients in which cooperation might be a
factor, the splint can be cemented after the patient is
anesthetized and before surgical preparation in the oper-
ating room. In cases in which a splint has been made to a
surgically created arch form, the splint has to be cement-
ed after the maxillary osteotomy is completed and the
segments have been mobilized. This procedure can be
difficult, as the segments are mobile and maintaining a
dry field can be difficult. Adequate assistance from the
surgeon and assisting personnel are required to hold the
segments in place and maintain a dry field.
American Journal of Orthodontics and Dentofacial Orthopedics Figueroa and Polley 3
Volume 115, Number 1

Fig 2. A, Intraoral appliance in working model. Note transpalatal bar as well as interdental bars to increase rigidity. B,
Vertical wires soldered perpendicular to labial aspect of intraoral splint. Upper portion of wire to be used as intraoral
hooks and lower extensions to be used for external traction hooks. C, Facial photograph of patient with cheek mark-
ings identifying approximate center of rotation of maxilla to be used as guidelines to bend external traction hooks. D,
External traction hooks with eyelets for connecting wire to RED device. Note position of eyelets at the level of the floor
of the nose and above approximate center of resistance of maxilla. External traction hooks have been bent to com-
fortably clear upper lip.

Surgery and Rigid External Distraction Device
Placement
The indications, details of surgery, and placement
of the cranially fixed rigid external distraction (RED)
device have been previously reported.8 A complete Le
Fort I osteotomy is performed, including pterygomax-
illary and septal dysjunction, with mobilization. Metal-
lic markers are placed above and below the osteotomy
and in the anterior aspect of the maxilla for follow-up,
and the soft tissue incision is closed. In young children,
a modified high LeFort I osteotomy, with minimal
downfracturing, is required to avoid disturbing devel-
4 Figueroa and Polley
Fig 3. Intraoral appliance used to deliver distraction
force to the maxilla. Note circumdental wiring.
Fig 4. A, Intraoral splint made with an orthodontic head
gear face bow with long external outer bow. B, Complet-
ed intraoral appliance made from a head gear face bow.
The outer bow has been bent to form the traction hooks.
Note small soldered hooks (arrow) to be used during the
facial mask retention phase after distraction.
oping tooth buds (Fig 5). Every effort is made at the
time of surgery to make an osteotomy cut that will
direct the maxillary segment with the appropriate hori-
zontal and vertical vectors to prevent the creation of an
anterior open bite or elongation of the lower face. In
younger patients, the presence of tooth buds may not
allow placement of the osteotomy in the desired direc-
tion, making the placement of the traction hooks
extremely important to control maxillary vertical and
horizontal movements. Once the maxillary osteotomy
American Journal of Orthodontics and Dentofacial Orthopedics
January 1999
Fig 5. Intraoperative view of a modified high LeFort I
osteotomy in 6-year-old patient. Note proximity of the
osteotomy to the infraorbital nerve (arrow). Three metal-
lic bone markers were utilized for postoperative follow-
up. Traction hook in the foreground.
Table I. Diagnosis and sex distribution of the sample
Diagnosis N Male Female
UCL/P 7 5 2
BCL/P 5 4 1
Facial cleft and BCL/P 2 1 1
Total 14 10 4
is completed, the halo portion of the RED device is
adjusted for the width of the neurocranium and is rigid-
ly fixed around the head with two or three scalp screws
on each side. The vertical bar of the RED is in the cen-
ter, sufficiently anterior and also parallel to the facial
plane. Initially the vertical facial bar is removed as the
traction forces are not applied until 3 to 5 days after
surgery, facilitating postoperative management and
feeding.
Distraction Protocol
A sample of 14 patients with various cleft types
(Table I) underwent distraction with the RED device
(Fig 1). The vertical bar was connected to the halo and
the horizontal bar with the distraction screws and was
placed at the appropriate vertical level based on the
vector needed to obtain the desired maxillary move-
ment 4 days (with children) or 5 days (with teenagers
and adults) after surgery. The force vector is deter-
mined by clinical evaluation and through cephalomet-
ric prediction tracings (Fig 2). A 25 gauge surgical wire
was used to connect the traction hook to the traction
screws (Fig 1).
Distraction was performed at home by turning the
activating screw at a rate of 1 mm per day (2 turns).
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 115, Number 1
Fig 6. Six-year-old female with left unilateral cleft lip and
palate and maxillary hypoplasia treated with maxillary
distraction with RED. Predistraction (A) and postdistrac-
tion (B) photographs. Note improvement in facial con-
vexity, cheek projection, and balance of face. C, Patient
underwent 6 to 8 weeks of retention with a removable
face mask with elastic traction.
Figueroa and Polley 5
Fig 7. Anatomic landmarks: sella (S), center of sella turci-
ca; nasion (N), most anterior point of nasal frontal suture;
anterior nasal spine (ANS), most anterior point of the
spine; A point (A), most anterior limit of the maxillary alve-
olar bone at the level of the incisor root apex; posterior
nasal spine (PNS), intersection between the nasal floor
and the posterior contour of the maxilla; apex of maxillary
incisor root (U1A), uppermost point of the incisor root; tip
of maxillary incisor crown (U1T), maxillary incisor edge;
tip of mandibular incisor (L1T), mandibular incisor edge;
apex of mandibular incisor root (L1A), lowermost point of
the mandibular incisor root; B point (B), most anterior limit
of the mandibular alveolar bone at the level of the incisor
root apex; pogonion (PG), most anterior limit of the
mandibular symphysis; menton (ME), most anterior point
of the mandibular symphysis; gonion (GO), the point at
the greater convexity of the mandibular gonial region.
Reference planes: sella-nasion plane (SN); palatal plane
(PPL), line through ANS and PNS; maxillary incisor axis
(U1), line passing through U1A and U1T); mandibular
plane (Mand Pl), tangent to the lower border of the
mandible through ME and GO.
The patients were followed weekly to assess bone con-
solidation and to make adjustments in the vertical posi-
tion of the horizontal traction bar and screws, to main-
tain control over the maxillary position.
Once the appropriate amount of distraction was
achieved, the RED system was left in place for 2 to 3
weeks to permit bone consolidation. The RED device
was removed in the clinic. After the RED device was
6 Figueroa and Polley
Fig 8. Predistraction (solid line) and postdistraction (bro-
ken line) average cephalometric tracings for all patients.
Note maxillary advancement with correction of negative
overjet and improvement of skeletal convexity, upper lip
and nose advancement, and minimal changes in
mandibular position.
removed, the labial hooks were cut. Positive traction
was continued by means of elastic traction through an
orthodontic face mask, using the intraoral hooks (Fig
6). For this purpose, one or two 6 oz elastics were used
on each side. The retention period after active distrac-
tion was between 6 and 8 weeks. Although not done in
this series of patients, if orthodontic appliances are in
place, interarch elastics can be used to further improve
occlusal relations.
CEPHALOMETRIC EVALUATION
The preoperative and postretention lateral cephalo-
metric radiographs were used for analysis. The postre-
tention radiographs were obtained 3 to 4 months after
distraction. The radiographs were traced, and 13
anatomic landmarks were recorded (Fig 7). All tracings
were done by a single investigator (AAF). Availability
of serial radiographs in all patients permitted landmark
verification. All x-rays were corrected to 0% magnifi-
cation. We looked at the recorded anatomic landmarks
and calculated 14 measurements, 7 angular and 7 linear
(4 horizontal and 3 vertical). For the linear measure-
ments, an x-y coordinate system with the S-N plane as
American Journal of Orthodontics and Dentofacial Orthopedics
January 1999
Fig 9. Predistraction (solid line) and postdistraction (bro-
ken line) average tracings of the maxilla for all patients.
Note minimal changes in incisor position relative to the
maxillary palatal plane.
the horizontal was used. Linear horizontal changes
were measured relative to a line perpendicular to the S-
N plane, passing through sella, and vertical changes
were measured perpendicular to the S-N plane. The
preoperative and postoperative cephalometric values
were statistically analyzed by means of a paired t test.
RESULTS
All of the surgery and RED device placement in
this series was performed by a single surgeon (JWP).
Perioperative antibiotics were routinely used. All
patients began routine oral hygiene and an unrestricted
soft diet 24 hours postoperatively. No intermaxillary
fixation nor bone grafts were used.
There was no surgical morbidity in any of the 14
patients in this series. There were no problems with
bleeding or infection. None of the patients required a
blood transfusion; there were no problems of dental
injury, avascular necrosis, or gingival injury. There
were no complications with wearing the external
device, including pain, discomfort, or loosening during
the distraction process. The intraoral splint remained
intact in all patients through the active and retention
phases. None of the families had difficulty following
the distraction instructions.
The predistraction and postdistraction angular and
linear cephalometric measurements are given in Tables
II and III. The average predistraction SNA angle was
77.6° and the postdistraction SNA angle was 85.3°, for
an average increase of 7.7°. The average predistraction
ANB was -1.2° and postdistraction was 7.3°, with an
increase of 8.6°. The skeletal angle of convexity
increased postdistraction by 17.2°. All of these three
measurements were statistically significant. The hori-
zontal ANS change between predistraction and post-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 115, Number 1
Table II. Angular changes after RED (n = 14)
Measurements Postdistraction
(degrees) Predistraction (4 months) Difference Significance
SNA 77.6 ± 5.6 85.3 ± 5.6 7.7 ± 2.9 **
SNB 78.8 ± 4.0 77.9 ± 4.1 –0.8 ± 1.8 NS
ANB –1.2 ± 3.5 7.3 ± 3.0 8.6 ± 3.6 **
Convexity –3.5 ± 7.5 13.7 ± 6.0 17.2 ± 7.3 **
(NAPg)
Mand Pl/SN 39.2 ± 6.7 41.4 ± 5.9 2.2 ± 2.4 * Ul-y
angle
U1 -PPL 100. 7 ± 15.7 98.8 ± 14.4 –1.2 ± 11.3 NS
angle
*P < .01, **P < .001.
distraction cephalometric radiographs was 7.1 mm, and
the average horizontal advancement of the A point after
distraction was 8.3 mm. The horizontal advancement at
the upper incisal edge averaged 11.6 mm, and all
patients had a positive correction of their overjet with
an average 12.7 mm change. All of the linear horizon-
tal changes were significant (P < .001) between predis-
traction and postdistraction measurements. The desired
treatment goals were obtained in all patients. The ver-
tical changes in the position of ANS, A point, and
upper incisor edge were small and not significant.
None of the patients resulted with an open bite. The
mandibular plane angle changed 2.2°. The average
skeletal changes after RED are shown in Fig 8.
The predistraction and postdistraction dental changes
are also given in Tables II and III and Fig 9. The change
in the angle of the upper incisor edge to the palatal plane
averaged -1.2° for all patients, and it was not statistical-
ly significant. None of the patients in this series resulted
with interdental spaces created posterior to the most dis-
tal point of anchorage of the intraoral splint.
DISCUSSION
It has been estimated that 25% to 60% of all
patients born with complete unilateral cleft lip and
palate will require maxillary advancement to correct
the maxillary hypoplasia and improve aesthetic facial
proportions.11,12 Patients with severe cleft maxillary
deficiency are difficult to treat with standard surgi-
cal/orthodontic approaches. These patients have maxil-
lary hypoplasia (vertical, horizontal, and transverse
dimensions) and often thin or structurally weak bone.
The hypoplasia in cleft patients is also compounded by
residual palatal and alveolar fistulas, absent and aber-
rant dentition, pharyngeal flaps, and scarring of the
palatal and pharyngeal soft tissues.
The physical deformities associated with maxillary
hypoplasia contribute to multiple functional deficien-
cies. These include severe malocclusions that result in
Figueroa and Polley 7
Table III. Horizontal (x) and vertical (y) linear changes
after RED (n = 14)
Landmark-axis Change (mm)
ANS-x 7.1 + 3.9**
ANS-y –0.4 + 3.0
A Point-x 8.3 + 3.3**
A Point-y –1.3 + 3.4
U1-x 11.6 + 4.6**
–1.8 + 3.5
Overjet 12.7 ± 3.0**
**P < .001.
compromised mastication and speech and nasal pha-
ryngeal airway patency. The severe concave facial pro-
file has negative psychosocial ramifications. Current
protocols for the treatment of maxillary hypoplasia in
cleft patients rely on a surgical/orthodontic approach,
including a LeFort I maxillary advancement with con-
comitant fistula closure, and maxillary and alveolar
bone grafting. This surgery includes rigid internal fix-
ation hardware for stabilization of the repositioned
maxilla in the postoperative period.
The long-term results of cleft patients with maxil-
lary deficiency treated in such fashion have been
reported and allude to increased relapse tendency
(greater than 20%) after maxillary advancement.13-16
All of the patients in our series, if they had undergone
correction of the deformity with a standard orthognath-
ic approach, would have also required mandibular set-
back surgery because of the severity of the maxillary
hypoplasia. The main disadvantage to this two-jaw
approach for cleft patients is that the majority of them
have a mandible that is normal in both size and posi-
tion or even small and retrognathic,17-24 Setback of the
mandible in an effort to reduce the amount of maxillary
advancement compromises final lower facial form and
esthetics. Expansion of the soft tissue facial mask
yields the most pleasing long-term aesthetic facial bal-
ance and harmony. This concept is extremely important
in cleft patients.25
The concept of gradually advancing the maxilla
after LeFort I corticotomy was originally presented by
Molina and Ortiz-Monasterio.26 In their technique, an
orthodontic face mask with elastics was used to deliv-
er the traction force to the maxilla. This technique has
several shortcomings, such as not delivering controlled
forces, pressure sores on the chin and forehead, com-
pliance, and most importantly the inability to advance
the maxilla sufficiently to correct severe cleft maxillary
hypoplasia. We have used this face mask approach
after complete maxillary osteotomy with disappointing
8 Figueroa and Polley American Journal of Orthodontics and Dentofacial Orthopedics
January 1999

A
C

B D
Fig 10. Profile photographs and cephalometric radiographs of a 10-year-old patient with bilateral cleft lip and palate
and severe maxillary hypoplasia before (A and B) and after (C and D) distraction. Note dramatic improvement in facial,
skeletal, and dental relations after a 16 mm total maxillary advancement with correction of anterior crossbite. (Printed
with permission, J Craniofacial Surg 1997;8:181-5.

results.27 The patients were undercorrected with resid-
ual anterior crossbites. This limited maxillary skeletal
response has also been observed by others.28-30 These
unfavorable experiences prompted us to modify the
technique and use a RED device.
RED uses a skeletally (cranial) fixed distraction
device that allows for predictable control over the dis-
traction process. The RED device is adjustable, offering
the ability to change the vertical and horizontal vector of
distraction, at any time, without discomfort to the
patient during the distraction process. The difference
between the two systems is evidenced by the greater
maxillary advancement obtained in those patients who
underwent RED, compared with those reported in
patients who underwent face mask distraction.27-30
In the past, it has been virtually impossible using
maxillary advancement alone to treat patients with
severe maxillary deficiency. With the use of RED, a
severely hypoplastic maxilla can be repositioned and
maintained to the desired horizontal and vertical posi-
tion without the use of bone grafting and fixation hard-
ware (Fig 10). Contrary to the use of protraction face
mask,31,32 with or without osteotomy, maxillary
advancement with distraction using the RED system
can be done with minimal alterations on mandibular
position (Fig 8).
Maxillary advancement at the LeFort I level with
the RED device allows for complete versatility in both
the amount and direction of the distraction process.
This control on maxillary movement is feasible
American Journal of Orthodontics and Dentofacial Orthopedics Figueroa and Polley 9
Volume 115, Number 1

Fig 11. Preoperative (A and B) facial profile view and intraoral view of a 51⁄2 year old boy with right unilateral cleft lip
and palate and bilateral crossbites. Facial and intraoral views 3 months after distraction (C and D). Note improvement
in facial convexity and lip and nose relations, as well as correction of the crossbites. The intraoral splint is still secured
with circumdental wires and is being used for the retention period after distraction.

because of the design of the RED device system. The
external distraction system allows complete vertical
adjustability of the distraction screws mounted on the
horizontal bar. The design of the intraoral splint, with
placement of the external traction hooks located at the
level or above the palatal plane, assures the clinician
that the vector of the distraction force can be controlled
relative to the position of the center of mass of the max-
illa. It is believed that the center of resistance, of the
not osteotomized maxillary bone, is located approxi-
mately at the apex of the maxillary premolars in the lat-
eral view.9,10 With the RED system, one can control
and change as needed, the force vector that passes
through (straight advancement) or above (downward
advancement) the center of resistance of the maxilla
(Figs 1 and 2). This is one of the main advantages of
RED over internal devices that inherently have limited
vector control.
Before bending the traction hooks, the clinician can
transfer the approximate center of resistance of the
maxilla from the cephalometric radiographs and from
the clinical examination to the face of the patient. The
skin is marked, corresponding to the center of resis-
tance, and the external traction hooks are bent to the
desired position (Fig 2). After connecting the distrac-
tion screw with the traction hook, the clinician can
evaluate the direction of the distraction force and can
adjust it, relative to the center of mass or resistance of
the maxilla (Fig 1).
Because the intraoral splint is made rigid enough,
preventing permanent deformation of the traction
hooks, the use of casted full coverage rigid splints is
not necessary. The slight flexibility present in the trac-
tion hooks allows for energy storage that may result in
continuous force to the maxilla between activations.
This continuous tension is believed to be conducive to
osteogenesis,33,34 a favorable event during the distrac-
tion process. Our current experience indicates that the
10 Figueroa and Polley American Journal of Orthodontics and Dentofacial Orthopedics
January 1999

Fig 12. Preoperative facial profile view and intraoral view in a 12-year-old female with right cleft lip and palate with max-
illary hypoplasia, anterior crossbite, and open bite (A and B). Postoperative views (C and D) after maxillary distraction
with RED demonstrating improvement in facial convexity, fullness of the infraorbital region, and improved lip and nose
relations. The intraoral view demonstrates correction of anterior crossbite and open bite. Degree of maxillary advance-
ment is shown by the position of the second maxillary premolar in full Class II relation after distraction (arrows).

use of a commercially available face bow facilitates the
fabrication of the intraoral splint. The outer face bow
wire has significant diameter to allow for the necessary
rigidity. The amount of necessary soldering is also min-
imized as the outer bows are used as the traction hooks.
Care must be taken to bend the traction hook while the
outer bow arms are long; working with short segments
of wire of heavy diameters is difficult. The commer-
cially available face bow is indicated for those patients
with a dental alveolar arch of sufficient size and form
to facilitate contouring the inner bow. If the dental alve-
olar arch is irregular or too small, it will be difficult to
obtain close adaptation to the teeth, which makes
placement of the required circumdental wires a difficult
and unstable process. For small or irregular arches, we
prefer to bend our own splint with appropriate gauge
wire. The advantages of the described intraoral splint
are various and include the following:
• It is custom designed, which is imperative, especially in
patients with clefts that present with severe dental malpo-
sitions and collapsed cleft arch segments.
• The device is inexpensive and easily constructed by the
orthodontist.
• It is hygienic, comfortable, and nontraumatic.
• It does not interfere with speech and eating.
• Simultaneous orthodontic movement, such as correction of
dental rotations, as well as expansion, can be performed.
• The active and retention intraoral devices are the same.
• The vectors of distraction can be changed at any time dur-
ing the distraction process without discomfort to the
patient, thus allowing for force vector changes as needed.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 115, Number 1
The use of the cranium as an anchorage base for the
stabilization after maxillofacial surgery is not a new
concept.35 Not even the youngest patients had com-
plaints or problems with wearing the device throughout
the distraction process. No special scalp pin care is re-
quired and the use of ointments and creams at the scalp
pin interface is discouraged. The patients simply sham-
poo and wash their hair with the device in place. The
RED device is removed in the clinic after the rigid reten-
tion phase usually without the use of local anesthesia.
Contemporary surgical/orthodontic approaches for
the treatment of maxillary deficiency in cleft patients is
usually dependent on the patient having reached skele-
tal maturity before the reconstructive surgery can be
performed. The RED technique for maxillary distrac-
tion osteogenesis eliminates the negative technical fac-
tors associated with traditional orthognathic surgery in
patients in transitional dental development. An osteoto-
my with complete mobilization is required with no
repositioning or placement of bone grafts. Rigid inter-
nal fixation hardware is not used, eliminating the risk
of dental injury during plate stabilization; thus this
technique can be used throughout childhood. The only
limitations in the application of this technique for
patients with severe skeletal hypoplasia include ade-
quate dentition (primary or permanent) for fixation of
the intraoral splint and patient tolerance to the external
distraction device. Because the RED system uses den-
tal support, the presence of a healthy dentition is
required. Skeletal anchorage for maxillary traction
hooks or osseointegrated implants may need to be con-
sidered for patients with inadequate dentition. Rigid
external distraction has allowed us to effectively treat
patients with severe maxillary skeletal hypoplasia from
the age of 5 years and up (Figs 11 and 12). No longer
is it necessary to wait years for the patient to reach
maturity before their severe maxillary facial deformity
is corrected with the associated functional, esthetic,
and psychosocial benefits.
All patients treated with RED are cautioned that a
percentage will require a final “finishing” LeFort pro-
cedure at skeletal maturity. It is anticipated that this
procedure will not require a “major movement,” thus
enhancing stability. This technique provides an excel-
lent modality for correcting severe maxillary deficien-
cy in patients with facial clefting and other anomalies
with structurally thin bone in the maxilla (ectodermal
dysplasia, Johansson Blizzard syndrome, etc.).
Modifications of this technique are undergoing
clinical trials to advance not only the maxilla at the
LeFort I level but also advancement at the LeFort II, III,
monoblock, and fronto-orbital levels. This article
reports our preliminary experience with this technique.
Figueroa and Polley 11
We will prospectively follow these patients to evaluate
the stability of maxillary distraction, and its effects on
facial, dental, and velopharyngeal development.
CONCLUSIONS
Maxillary distraction osteogenesis after complete
osteotomy with the RED technique is a highly effective
treatment modality to manage cleft-related maxillary
hypoplasia. The technique allows for vector control of
the osteotomized maxilla throughout the distraction
process. It has been used, with minimal morbidity, in
children as young as 5 years of age, adolescents, and
adults. In all patients treated with RED the initial neg-
ative skeletal convexity and dental overjet were satis-
factorily corrected with the associated favorable soft
tissue changes.
We thank Dr. Eric Jein-Wein Liou for computer and
statistical assistance.
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